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OR Excellence Awards - September 2020 - Subscribe to Outpatient Surgery Magazine

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Dr. Donnenfeld emphasizes 10 of the 29 cases that the FDA cited were associated with the intra- cameral use of Moxeza, an FDA-approved topical drop that is not indicated for intraocular injection. Moxeza contains xanthan gum and sorbitol, among other inactive ingredients, which have been linked to TASS. The drug's labeling notes it is for topical use only and should not be repackaged or com- pounded for intraocular injection. "One third of the TASS cases were caused by the inappropriate use of a medication that has nothing to do with bulk moxifloxacin," says Dr. Donnenfeld. The American Society of Cataract and Refractive Surgeons (ASCRS) and the American Academy of Ophthalmology (AAO) have written letters to the FDA to express their support for the use of bulk moxifloxacin, according to Dr. Donnenfeld. He says losing the use of bulk moxifloxacin would force sur- geons to explore other more expensive alternatives, which would take a larger cut out of CMS's cataract surgery bundle. "Moxifloxacin is one of the most important medica- tions used to prevent endophthalmitis," says Dr. Donnenfeld. "There have been thousands of studies showing it reduces endophthalmitis with millions of patients having received the medication, making it one of the most studied drugs in ophthalmology. Dr. Donnenfeld believes the risk of not using bulk moxifloxacin is greater than the risk of using compounded medications. "That has become less of a problem in recent years now that ophthalmic facilities are partnering with reputable com- pounding pharmacies," he says. "Most pharmacies practice safe levels of sterility when compound- ing their medications. Making access to moxi- floxacin more onerous for surgeons would place patients at risk. We simply want to maintain the status quo." All intraocular use of moxi- floxacin is off label, points out Roy S. Chuck, MD, PhD, chairman of the department of ophthalmology and visual sciences at Albert Einstein College of Medicine Montefiore Medical Center in the Bronx, N.Y. However, he was sur- prised to learn some surgeons are using Moxeza, a drug that shouldn't be used for intracameral injections. Many surgeons began injecting non-preservative forms of moxifloxacin inside the eye to avoid issues of compliance with post-op antibiotic drop regi- mens, according to Dr. Chuck. "There's no proof that any antibiotic injected into the eye pre- or postoperatively prevents endoph- thalmitis," says Dr. Chuck. "Trials suggest it's effec- tive, but it's never been definitively proven. I'm still a believer in using intracameral antibiotics, but we need a product that's well-regulated." Promising progress There have been fewer TASS outbreaks in recent years. "Ophthalmic professionals have taken pre- ventative measures to heart and are doing a good job of limiting risk factors," says Dr. Chuck. "There are many variables that contribute to the develop- ment of TASS, but at least there are protocols to fol- low that effectively lower the risk." You should allow adequate time for the proper cleaning and sterilization of ophthalmic instrumen- tation, according to ASCRS's TASS guidelines (osmag.net/8SnxWC). Transport soiled instruments to the reprocessing area in a closed container and ensure lumened instruments are thoroughly rinsed. Also be sure viscoelastic agents don't have a chance to dry on used instruments by immediately wiping them with a damp, lint-free cloth and flushing or immersing them in sterile water at the point of use. Clean ophthalmic instruments separately from other types of instrumentation. Also use disposable cannulas and tubing whenever possible. "Incidence remains low because facilities are following preventative protocols," says Dr. Donnenfeld. "However, constant vigilance remains essential." OSM 6 6 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • S E P T E M B E R 2 0 2 0 Moxifloxacin is one of the most important medications used to prevent endophthalmitis. — Eric Donnenfeld, MD

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